A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?

Notify the client's family to come visit client

Instruct the client return to their room

Ask the unlicensed assistive personnel (UAP) to push fluids

Assess the client's lung fields and temperature

Answer and Explanation

The Correct Answer is D

A. Notifying the client's family may be appropriate after assessing the client and identifying the cause of the confusion. However, it is not the first action, as the priority is to determine if the confusion is due to a medical condition requiring immediate attention.

B. Instructing the client to return to their room addresses the wandering behavior but does not address the underlying cause of the new onset confusion. Without further assessment, this action may delay necessary interventions.

C. Asking the UAP to push fluids assumes that dehydration is the cause of the confusion without evidence. While encouraging hydration may be beneficial later, it is essential first to assess for other potential causes, such as infection or hypoxia.

D. Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection (e.g., pneumonia or urinary tract infection) or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Decreased PaO2 <60mmHg: A hallmark of fat embolism syndrome (FES) is hypoxemia, which results in a PaO2 less than 60 mmHg. This is a key indicator of the severity of respiratory compromise in FES and ARDS.

B. PaO2 greater than 80mmHg: This would not be consistent with FES. Fat embolism often causes significant hypoxemia, and PaO2 greater than 80 mmHg would indicate adequate oxygenation.

C. Decreased platelet count and hematocrit levels: In fat embolism syndrome, there is often a decrease in platelet count and hematocrit due to disseminated intravascular coagulation (DIC), which can occur as a complication of fat embolism.

D. Changes in ST segment and T-wave: Electrocardiographic changes, including changes in ST segment and T-wave, are commonly seen in fat embolism syndrome due to myocardial injury, hypoxemia, or shock.

E. PaCO2 40mmHg: A PaCO2 of 40 mmHg is within normal limits and does not indicate any significant respiratory distress or abnormality that would be expected in fat embolism syndrome.

A. Obtain intravenous access. B. Computed tomography (CT) of the chest C. Thoracentesis D. Obtain ABGS. E. Pulmonary Function Tests (PFTS) F. Prepare for insertion of a chest tube

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Potential Prescription	Anticipated	Non- essential	Contraindicated
Obtain intravenous access.	✓
Computed tomography (CT) of the chest	✓
Thoracentesis		✓
Obtain ABGS.	✓
Pulmonary Function Tests (PFTS)			✓
Prepare for insertion of a chest tube	✓

Rationale

Obtain intravenous access: Anticipated. IV access is crucial for administering fluids, medications (like pain management), and potentially blood products if needed.
Computed tomography (CT) of the chest: Anticipated. A CT scan provides a detailed image of the chest cavity and can confirm the diagnosis of pneumothorax, as well as identify the size and location of the air accumulation.
Thoracentesis: Non-essential. A thoracentesis is a procedure to remove fluid from the pleural space. In a pneumothorax, the issue is air accumulation, not fluid. While a hemothorax (blood in the pleural space) can sometimes accompany a pneumothorax, the provided information does not indicate this. A chest tube is the appropriate intervention for air.
Obtain ABGs (Arterial Blood Gases): Anticipated. ABGs provide essential information about the client's oxygenation, ventilation, and acid-base balance. Given the client's low O2 saturation and respiratory distress, ABGs are necessary to assess the severity of respiratory compromise.
Pulmonary Function Tests (PFTs): Contraindicated. Pulmonary function tests are not appropriate in the acute setting of a pneumothorax as they can exacerbate the condition and are not useful for immediate management.
Prepare for insertion of a chest tube: Anticipated. A chest tube is the definitive treatment for a pneumothorax. It allows for the evacuation of air from the pleural space and re-expansion of the lung. Given the client's symptoms (dyspnea, low O2 saturation, absent lung sounds), a chest tube is highly likely to be required

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A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D"]

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first?

Which medications would be most appropriate to administer to a patient experiencing an acute asthma attack? Select all that apply.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

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Which assessment data would warrant immediate intervention by the nurse?

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The nurse is caring for a client diagnosed with end-stage chronic obstructive pulmonary disease (COPD). Which of the following data warrants immediate intervention by the nurse?

A client receiving low molecular weight heparin subcutaneously to prevent DVT following hip replacement surgery reports to the nurse that she observed small purple hemorrhagic areas on the right and left sides of the abdomen. Which action should the nurse implement?